Failure to Supervise High-Risk Resident Resulting in Elopement and Immediate Jeopardy
Penalty
Summary
The facility failed to ensure effective management and supervision of residents at high risk for elopement, resulting in an actual elopement incident that created an immediate jeopardy situation. Review of job descriptions, facility and clinical records, and staff interviews revealed that both the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not fulfill their responsibilities to manage the facility in accordance with applicable laws, regulations, and standards of practice. Specifically, the NHA was responsible for operating the facility and ensuring policies were uniformly applied, while the DON was responsible for directing nursing services to maintain the highest quality of care. Despite these defined roles, the facility did not provide the required supervision for residents identified as high risk for elopement. This lack of proper oversight and adherence to facility policies led to a resident elopement, which was identified as an immediate jeopardy event. The report cites that the facility did not ensure residents received treatment and care in accordance with professional standards of practice and facility policies, as required by state regulations. The findings are based on direct review of policies, job descriptions, and interviews, confirming that the fundamental principles of resident care and supervision were not upheld.